Does etomidate affect prognosis in septic shock patients treated with hydrocortisone?

Introduction

Etomidate is well tolerated and not inferior to ketamine but because it is implicated in critical illness-related corticosteroid insufficiency (CIRCI) [1], its utilization in septic shock patients is controversial. In our ICU, the standard of care is to treat every septic shock patient with 200 mg hydrocortisone for at least 5 days. The aim of our study was to compare prognosis of septic shock patients intubated with etomidate with patients intubated without etomidate.

Methods

Observational study during a 2-year period including every septic shock patient. We compared the patients' prognosis when intubated with etomidate (E group) to patients intubated without (NE group). We recorded demographic characteristics, results of a cosyntropin test, dose and length of vasopressors and hydrocortisone and outcome. The main endpoint was mortality in the ICU. The secondary endpoints were the length of shock, the dose of vasopressors and hydrocortisone in the ICU and the plasma cortisol level.

Results

We evaluated 62 patients in the E group and 31 in the NE group. Although SAPS II on admission was higher in the E group (54 (42 to 64) vs 45 (32 to 54)*), the total dose (95 mg (37 to 195) vs 66 mg (31 to 112)) and total duration (54 hours (36 to 91) vs 52 hours (31 to 81)) of vasopressors from day 0 to day 5 was not different between groups. However, the cosyntropin responder rate was higher in the non-E group (40% vs 18%*), hydrocortisone treatment duration (168 hours (78 to 216) vs 96 hours (72 to 144)*) and total dose of hydrocortisone (1,200 mg (500 to 1,625) vs 750 mg (350 to 1,125)*) was higher in the E group than in the non-E group. Finally, mortality in the ICU was not different between groups (32% vs 27% in the E and the non-E groups, respectively). *P < 0.05.

Conclusions

In this study on septic shock treated with a short course of hydrocortisone, patients intubated with etomidate presented a CIRCI more frequently than patients intubated with another drug and needed a longer and higher dose of hydrocortisone treatment. However, length of shock, dose and duration of vasopressors and mortality were not different between groups. Etomidate-induced CIRCI when treated with hydrocortisone was not associated with a poorer outcome in our study. A comparison between etomidate and ketamine should be performed in this population.